My uncle took out a life insurance with Sanlam Sky Solutions in June 2016 he unfortunately passed away September 2017. We logged a claim with Sanlam Sky Solutions they told us that they will get back to us, they did not mention a time frame of when they’ll get back to us. After several months we decided to contact them to ask them how far they are with the claim. They told us that they need the medical history of my uncle from the the employer and GP. We had no problem with giving them the consent to get the records. Our only problem was they wanted us to pay an amount of R2394 for these medical records. We could not pay this amount so Sanlam eventually paid to get these medical records and they told us again that they’ll get back to us.

They dragged the case again we decided to contact the ombudsman with our case. Sanlam Sky contacted us after to tell we had filled in the wrong forms and they attached the correct forms on the email. A few days later, we got an email from them telling us that my uncle did not disclose a certain illness meaning that they will not pay out the life cover.

Sanlam Sky then refunded the monthly premiums my uncle was paying they even subtracted the amount they wanted for the medical records. The life cover claim amount was not even disclosed.

We asked Sanlam Sky to show us the insurance form my uncle filled out so that we can see that he did not disclose the illness. They sent us a blurry looking scan that was one page. We couldn’t see anything properly including my uncle’s signature and details.

The ombudsmen finally responded they told us that there is no case and that they agree with Sanlam Sky.

Sanlam Sky did not ask my uncle to get a medical test before taking out their insurance, the cover had no disclaimer of what sicknesses they cover or do not cover. Through these months out family went through hardships, my uncle did not get a funeral he deserved. The ombudsmen failed us.

Please help us.

2 Responses

Anna Senosi

A few days later we received an sms from an unknown number saying that Sanlam has received our claim request and that claims processing has begun with the ref number of FLO-180823-H56 and that we should call 0860302932 for more information. We proceeded to do so. The consultant told us that she cannot find the ref number on their system. She proceeded to say that their system sends out old messages imagine! So this false information

Anna Senosi

In accordance with the usual practice in this office your complaint file, including all documentation and correspondence, was re-allocated to me for further consideration of your complaint.

Having thoroughly considered all the written submissions that were received from both parties, I must inform you that I agree fully with the findings that were made by the ombudsman in her provisional determination of the 5th July 2018.

Having regards to the application form, Annexure 1, it is clear that the ticks to all the questions posed have been placed under the column titled “NO”. Furthermore, whilst I accept that some questions are blurred, question 3 is clear and as referred to above, has been responded to in the negative.

The medical information on file confirms that your late uncle had been diagnosed with a certain illness prior to the commencement date of the policy. The question referred to above should therefore have been answered in the affirmative. I therefore accept that there was non-disclosure on the part of your late uncle.

You contend that the insurer should have done medical testing at application stage to establish your late uncle’s medical history.

In general an insurer is required to make its own additional enquiries if the information disclosed by the insured reasonably raises an alarm or needs further elucidation. Based on the responses to the questions on the application form, all negative, further investigation was not warranted.
“…Insurers being in the business of taking a chance, are entitled to as much information as possible to enable them to calculate and quantify the risk they are asked to assume. Hence applicants for insurance are usually required to answer a series of questions on any circumstance that may have a bearing on the assessment of the relevant risk…
Moreover, since the facts affecting the risk are more often than not within the perculiar knowledge on insurance proposers, the law imposes a duty on them to make a full disclosure of the relevant facts known to them.” (bold own emphasis)

I enclose an email from the insurer dated 12 September 2018, Annexure 2. It confirms that the monies previously deducted for the cost of obtaining the medical information, have been refunded. Till today the money that was deducted for the medical report of my late uncle is not been refunded to us as specified on the above email.

For the reasons set out above, I am hereby confirming the correctness of the provisional determination as a whole. As this is our final determination, our file has been closed.

Assistant Ombudsman
The Office of the Ombudsman for Long Term Insurance
Tel: 021 657 5041
Fax no: 0866 582 652